What is the management of Vancomycin (an antibiotic) Intravenous (IV) infiltration?

Management of Vancomycin IV Infiltration

Immediately stop the vancomycin infusion, discontinue the IV catheter, and assess the extent of tissue injury; then establish new IV access at a different site to continue necessary antimicrobial therapy. 1

Immediate Actions

Stop Infusion and Remove Catheter

• Discontinue the vancomycin infusion immediately upon recognition of infiltration to prevent further tissue damage 1, 2
• Remove the infiltrated peripheral catheter and do not attempt to aspirate the infiltrated medication 1
• Document the volume of fluid infiltrated and the appearance of the affected site 2

Assess Tissue Damage

• Evaluate the infiltration site for signs of tissue injury including swelling, pain, blanching, coolness, and skin tightness 1, 2
• Vancomycin is classified as a vesicant antibiotic capable of causing tissue necrosis with extravasation, though severe complications are relatively uncommon (only 3 reported cases in one systematic review) 1
• Monitor for development of phlebitis, which occurs in 10-53% of patients receiving peripheral vancomycin depending on concentration 2

Supportive Care Measures

Local Wound Management

• Elevate the affected extremity to reduce swelling 3
• Apply warm or cold compresses based on institutional protocol (evidence is limited for specific temperature recommendations) 3
• Avoid applying pressure to the infiltrated area 2
• Monitor the site closely for progression to tissue necrosis, which may require surgical consultation if severe 1

Pain Management

• Provide appropriate analgesia as infiltration can cause significant discomfort 3, 2
• Document pain severity using a standardized scale 2

Re-establishing Vascular Access

Choice of New Vascular Access

• For continued vancomycin therapy, consider a midline catheter (MC) or peripherally inserted central catheter (PICC) rather than another short peripheral catheter (SPC) to reduce risk of repeat infiltration 1
• The 2018 IDSA OPAT guidelines state that mandatory use of a central catheter over a noncentral catheter for vancomycin is not necessary, though the evidence quality is very low 1
• If a peripheral catheter must be used, ensure vancomycin is diluted to ≤5 mg/mL concentration, as concentrations >5 mg/mL are associated with significantly higher rates of infusion-related complications (53.3% vs 10%) 2

Optimizing Vancomycin Administration to Prevent Recurrence

• Dilute vancomycin to a concentration of ≤5 mg/mL when administering through peripheral catheters 2
• Use continuous infusion via volumetric pump rather than intermittent bolus infusion when possible, as this reduces endothelial toxicity at therapeutic doses 4, 2
• Prolong infusion time to at least 1-2 hours (or 2 hours for loading doses of 25-30 mg/kg) to minimize vein irritation 1, 4
• Consider premedication with an antihistamine for large doses to reduce risk of red man syndrome 1

Common Pitfalls to Avoid

• Do not continue infusing vancomycin through an infiltrated line, as vancomycin's vesicant properties can cause progressive tissue damage 1, 3
• Avoid using concentrated vancomycin solutions (>5 mg/mL) through peripheral catheters, as this dramatically increases the risk of phlebitis and infiltration 2
• Do not assume all peripheral sites are equivalent—intermittent infusion through short peripheral catheters has higher complication rates than continuous infusion through midline catheters 1, 4
• Failure to monitor the IV site regularly during vancomycin infusion can result in delayed recognition of infiltration and more extensive tissue injury 2

Monitoring and Follow-up

• Reassess the infiltrated site every 4-8 hours for the first 24-48 hours to detect progression 2
• If tissue necrosis develops, obtain surgical consultation for potential debridement 1
• Document the incident and consider it when planning future vascular access strategies for this patient 2
• Ensure therapeutic vancomycin levels are maintained despite the interruption by checking trough levels at steady state 1